MEDICARE: MARY JUDITH WEAVER M.S. ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1790255149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JUDITH WEAVER M.S. ED.

Provider Business Mailing Address
First Line	:	3829 LASALLE DR APT 105
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-4755
Country	:	US
Telephone Number	:	814-657-5151
Fax Number	:

Provider Business Practice Location Address
First Line	:	1716 GREY FRIARS CHASE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-5435
Country	:	US
Telephone Number	:	757-648-3640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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Directions to “ MARY JUDITH WEAVER M.S. ED.” Practice Location

Language	Start Address	Practice Location

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